Patient Referral

Take the Quiz:

Is Palliative Care Right for You?

It only takes a minute to answer five key questions that can determine whether palliative care could be right for you or someone close to you. 

quiz-image.png

Is Palliative Care Right for You?

It only takes a minute to answer five key questions that can determine whether palliative care could be right for you or someone close to you. 

1. Do you have one or more chronic illnesses such as:

  • Cancer
  • Congestive heart failure (CHF)
  • Chronic obstructive pulmonary disease (COPD), emphysema, lung disease
  • Kidney failure
  • Liver failure
Yes
No

2. Do you have symptoms that make it difficult to be as active as you would like to be, or impact your quality of life? These symptoms might include:

  • Pain or discomfort
  • Shortness of breath
  • Fatigue
  • Anxiety
  • Depression
  • Lack of appetite
  • Nausea
  • Constipation
Yes
No

3. Have you experienced the following:

  • Difficult side effects from treatment
  • Eating problems due to a serious illness
  • Frequent emergency room visits
  • Three or more admissions to the hospital within 12 months, and with the same symptoms
Yes
No

4. Do you need help with:

  • Knowing what to expect
  • Knowing what programs and resources are available
  • Making medical decisions about treatment choices/options
  • Matching your goals and values to your medical care
  • Understanding the pros and cons (benefits/burdens) of treatments (e.g., dialysis, additional cancer treatments, surgery, etc.)
Yes
No

5. Do you need help with:

  • Coping with the stress of a serious illness
  • Emotional support
  • Spiritual or religious support
  • Talking with your family about your illness and what is important to you
Yes
No

Please select an answer

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